Provider Demographics
NPI:1477530228
Name:LIGHTHOUSE THERAPY SERVICES, LLC
Entity type:Organization
Organization Name:LIGHTHOUSE THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:920-451-8667
Mailing Address - Street 1:314 NIAGARA AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4128
Mailing Address - Country:US
Mailing Address - Phone:920-451-8667
Mailing Address - Fax:920-451-8799
Practice Address - Street 1:314 NIAGARA AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4128
Practice Address - Country:US
Practice Address - Phone:920-451-8667
Practice Address - Fax:920-451-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered302R00000XManaged Care OrganizationsHealth Maintenance Organization
Not Answered305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42194400Medicaid
WI42194400Medicaid